Eating Disorders Among Athletes

How to recognize clients at risk and ultimately become part of a multidiscipline team that helps elite athletes deal with the challenges of eating disorders.

Almost everyone wants to lose weight and drop that extra 5 or 10 pounds. But some people take that desire to extreme measures and will literally starve themselves to be thinner. While we usually associate eating disorders with sedentary clients, the truth is that more and more elite athletes are falling prey to unhealthy eating and exercise behaviors. Society admires the willpower, dedication and perseverance that athletes demonstrate in perfecting their sports. We tend to place elite athletes on the highest pedestal of celebrity, showering them with praise and respect. Yet, it is very easy for these athletes to get disconnected from the body in the extreme pursuit of perfection and athleticism.

Considerable evidence exists that competitive athletes in certain sports are at greater risk for developing disordered eating and eating disorders than the general population. For a good majority of the population, sports participation provides a healthy, enjoyable experience that helps build self-esteem and a feeling of mastery (Fulkerson et al. 1999) and can lead to a strong body image. However, some people who participate in sports—especially sports that equate leanness with enhanced performance—are more likely to start a pattern of disordered eating behaviors, which can ultimately progress to a dangerous eating disorder.

Prevalence of Eating Disorders in Athletes

So how prevalent are eating disorders among athletes? In a large-scale study of 1,445 Division I NCAA student athletes (Johnson, Powers & Dick 1999), many of the female athletes reported attitudes and symptoms that placed them at risk for anorexia nervosa or bulimia nervosa. Although no females met the American Psychiatric Association’s (APA) criteria for anorexia and only 1.1% met the criteria for bulimia, 2.85% were identified as having a clinically significant problem with anorexia and 9.2% as having a clinically significant problem with bulimia. There may have been others whose symptoms were not serious enough to be considered “clinically significant.” Also, more than 10% of the females reported binge eating on at least a weekly basis. There was little to no evidence of clinically significant problems with anorexia or bulimia in males, but 13.02% of males reported binge eating at least once a week.

The researchers theorized that the rates of eating disorder thoughts and behaviors would be even higher among less elite, Division II athletes and also thought that some athletes in the study might have minimized their symptoms to protect their schools’ athletic departments.

Although most athletes with eating disorders tend to be female, males are at growing risk—especially those who compete in sports that place a high emphasis on diet, appearance, size and weight requirements. Examples of these sports for men include wrestling, bodybuilding, crew, running (cross-country and track), football and horse racing.

Another group of researchers conducted a meta-analysis of 34 studies involving the relationship between sports participation and eating problems (Smolak, Murnen & Ruble 2000). They found that while sports can be a positive experience for some athletes, the same activities can constitute a risk factor for others. The implication of these findings is that it is not the sport per se that creates the risk for the athlete, but rather certain aspects of the sport and/or the sport environment. Put simply, there are particular personality variables that predispose an athlete to developing an eating disorder, and specific sport environments seem to create additional risk.

Types of Eating Disorders

Eating disorders are severe medical conditions that tend to become chronic if left untreated. These illnesses can be triggered or exacerbated by a number of factors, such as genetics, the environment and life events. Anorexia, bulimia and, particularly, exercise addiction can go undetected and undiagnosed for years.

Eating disorders typically begin with disordered eating and a disordered relationship to the body. Think of the behavior as a continuum, with disordered eating at one end and full-blown eating disorders at the other (riskier) end. The most common eating disorders include anorexia nervosa, bulimia nervosa and a third category called “eating disorders not otherwise specified.” Also, the APA’s Diagnostic and Statistical Manual of Mental Disorders IV-TR now includes criteria for binge eating disorder, a condition that is finally receiving appropriate recognition. The next sections will describe the different types of eating disorders, their prevalence rates and how fitness professionals can recognize the emergence of an eating disorder.

Anorexia Nervosa

Anorexia nervosa typically begins in adolescence and often persists into adulthood. A popular myth is that a diagnosis of anorexia is made only if a person has stopped eating completely. The truth is that patients with anorexia lose weight by restricting their food intake and exercising excessively; a subgroup of anorexics will also induce vomiting after meals. Some of these patients will go on to abuse laxatives and/or take diet pills.

Approximately 90%–95% of patients with anorexia are female (Buliket al. 2006). Even though the prevalence rates for men are much lower, males exhibit the symptoms of anorexia in the same way as women do. There are two critical time periods when anorexia tends to manifest: at age 13–14 or at age 17–18 (Yager & Powers 2007). Puberty and menopause are also periods that can pose a very high risk for developing anorexia.

The personality characteristics associated with anorexia include emotional restraint, rigidity, perfectionism and obsessiveness. People who develop anorexia usually take comfort in routines and do not like change. When one compares the traits of a “good athlete” with those of an anorexic client, there are a number of similarities (Thompson & Sherman 1999). A “good athlete” manifests mental toughness, a commitment to training, pursuit of excellence, “coachability,” unselfishness and performance despite pain. People with anorexia are likewise given to excessive exercise, perfectionism, over compliance, selflessness and a denial of discomfort. Since these traits are so similar, it is easy to see why a “good athlete” becomes an ideal candidate for developing anorexia. (For more information on signs of anorexia, see “Symptoms of Common Eating Disorders” sidebar.)

Anorexia tends to be most prevalent in nations where food is abundant and society places importance on a thin body ideal. The condition cuts across all socioeconomic lines and most ethnicities. Anorexia is slightly less common among African Americans, as compared with Caucasians, Hispanics and Asian Americans (Yager & Powers 2007).

The medical complications of anorexia are severe and can negatively affect the heart, endocrine system, skeleton, reproductive system, gastrointestinal system, kidneys and even the grey matter mass in the brain. According to the American Psychiatric Association, people with anorexia tend to feel cold all the time; suffer from severe constipation; fail to have regular periods; develop extremely dry skin, sometimes with a yellowish cast; and have brittle skin and nails (APA 2008).

The Female Athlete Triad

Anorexia nervosa has many of the same characteristics as a condition known as the female athlete triad. The three main symptoms associated with the female athlete triad are disordered eating, amenorrhea (loss of menses) and osteoporosis. Coaches are trained to look for these three signs among their athletes to alert them to the presence of an eating disorder. However, it is important for anyone who trains athletes to know that clients can suffer from the condition but not exhibit all three symptoms.

Fitness professionals must also keep in mind that the term female athlete triad is a misnomer because it seems to apply only to women. In fact, men can suffer from a similar condition: when males have anorexia, their hormone levels dip substantially and there is the same resultant drop in sex drive and bone loss as women experience.

Bulimia Nervosa

Bulimia nervosa is an eating disorder that is much more difficult to detect than anorexia. That’s because the client may appear to be healthy and may seem to have “normal” eating habits; however, a lot of disordered eating and purging occurs in secret.

The condition typically begins during late adolescence or early adulthood. People prone to bulimia tend to be normal weight or slightly overweight. Usually, bulimia starts after a period of dieting, which is why fitness professionals should be well trained in how dieting puts a person at risk for developing an eating disorder. As with anorexia, 90%–95% of patients with bulimia are female.

Generally, the personality of the bulimic individual is different from that of an anorexic. People with bulimia exhibit emotion dysregulation, impulsivity, perfectionism, self-destructiveness, low self-esteem, conflict avoidance and fear of abandonment. They are also more likely to have abused substances, such as drugs and—particularly—alcohol. (For more information on signs of bulimia, see the “Symptoms of Common Eating Disorders” sidebar.)

The medical complications related to bulimia nervosa are extensive and can be life threatening. The heart is affected because of electrolyte imbalances, and the heart muscles become weak. Esophagitis, chest pain and hernias are common because of persistent vomiting. Dental problems are severe because of the amount of enamel erosion and gum recession caused by chronic purging. Additionally, women who have had bouts of bulimia tend to have twice the rates of infertility, low birth weights and postpartum depression (Yager & Powers 2007).

It is important to know that bulimia is a disorder clouded in shame and secrecy. The bulimic person tends to be an all-or-nothing thinker who compensates for any lapses in diet by purging. For the majority of men and women with eating disorders, expressing any negative feelings is difficult. For bulimics, the constant overeating and purging are acts of self-destruction, which may be the only safe ways the person can express anger. Women and men with eating disorders commonly report that they internalize anger through binge-purge episodes. Also, many of those afflicted feel “worthy” of eating only if they have exercised that day.

Eating Disorders Not Otherwise Specified

The category of eating disorders not otherwise specified (EDNOS) includes all disordered eating behaviors that do not meet the exacting criteria for anorexia nervosa or bulimia nervosa. For example, someone who is driven to be very thin, has a distorted body image, restricts food occasionally but still has a regular menstrual cycle would fit into the EDNOS category. So would someone who chews and spits out food or an individual who binges late at night but doesn’t purge.

The hallmark of the conditions that fall under the EDNOS umbrella is the disordered eating. Athletes who suffer from disordered eating tend to have extensive knowledge about food and its energy/fat content. They may also weigh themselves frequently; eat secretly; overexercise to compensate for eating; or have an exaggerated preoccupation with weight, body image and other food issues. (For more information on signs of disordered eating, see the “Symptoms of Common Eating Disorders” sidebar.)

Unfortunately, there has been little research conducted to date on the epidemiology, course and outcome of this heterogeneous diagnostic group. What we do know centers mostly on one symptom cluster of EDNOS called “binge eating disorder.”

Binge Eating Disorder

Binge eating disorder (BED) is characterized by recurrent binge eating. An episode of BED is defined as having two main characteristics: (1) eating more food with in a 2-hour period than the average person within the same time period; and (2) feeling a lack of self-control during the episode. People who suffer from BED often exhibit a tremendous amount of distress about overeating. To compensate, they eat more rapidly than normal; continue to eat until they feel uncomfortably full; eat large amounts in the absence of hunger; eat in secret out of embarrassment; and feel disgusted, depressed and guilty after eating. (For more information on signs of BED, see the “Symptoms of Common Eating Disorders” sidebar.)

People with BED can be of normal weight, but most tend to be overweight and have repeatedly failed at dieting attempts in the past. As with anorexia and bulimia, BED is more common among women than among men. Interestingly, the prevalence of BED among people involved in weight loss programs is as high as 20%–30% (Spitzer et al. 1992). BED is present in all ethnic groups, with no one sub group showing a higher density (Yager & Powers 2007).

The medical complications of BED are similar to the complications associated with being overweight and obese. These include hypertension, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and cancer (Bulik et al. 2003). In one large study of twins, researchers reported that obese subjects with BED tended to have more health problems and were also significantly more likely to demonstrate dissatisfaction with their health than obese subjects without BED (Bulik et al. 2003).

For athletes with suspected BED, it can be helpful to isolate the specific factors that appear to trigger the eating binges. Fitness professionals who are aware that a client’s excessive exercise is due to the shame of binge eating should aim to make the client comfortable in the fitness setting and—while always staying within scope of practice—should initiate a discussion about positive body image. Keep in mind that a history of failed dieting attempts tends to make individuals with BED very resistant to committing to a fitness goal. So an initial goal could be to learn more about nondieting approaches to weight loss or to slowly start out walking for just 10 minutes a day.

Exercise Addiction

As fitness professionals, we often encourage clients to eliminate their stress by exercising regularly. The problem is that for some people, exercise becomes their only means of releasing tension. The addiction to exercise creeps in very insidiously, and one can quickly become dependent on the natural “high” that follows a workout.

Exercise addiction is one of the most difficult conditions to reverse, since people experience so many positive gains from exercising. Most athletes and regular exercisers will report an increase in symptoms of depression when they haven’t exercised for a few days. The withdrawal from exercise can be especially challenging because of the resultant depression. It is no wonder that most people who are addicted to exercise often report that they feel like “jumping out of their skin” when exercise is taken away from them.

If a client is suspected of having an exercise addiction, the best course is to slowly wean him off his fitness program, since it is often his only outlet for stress release. It is helpful to find opportunities for the client to learn how to develop better coping mechanisms that are less destructive. Depending on the individual, a referral to an allied health professional may be appropriate.

Which Athletes Are at Risk?

A number of factors predispose an athlete to developing an eating disorder. Risk factors include the following:

pressure from influential people (coaches or parents) to lose weight to improve sports performance

over involvement in sports, with limited other social and recreational activities

training even when sick or injured

training outside of scheduled practice times or more than other athletes on the team

Men are at highest risk for eating disorders when they participate in sports with a huge subculture of “weight cutting” (i.e., dropping weight quickly to qualify for a meet) to achieve a competitive edge; two examples are track and field and wrestling. Lightweight rowing also puts boys and men at high risk of developing disordered eating, extreme weight loss behaviors or eating disorders. Finally, sports such as swimming that require male or female athletes to wear revealing clothing can create an unhealthy body focus.

Some athletes tend to engage in competitive thinness and compare themselves with rivals who are thinner than them. This is especially true if the thin competitors are better performers, since this can provide the rationale for losing weight in harmful ways. Revealing uniforms tend to increase the likelihood of competitive thinness, because such attire encourages and facilitates unhealthy body comparisons.

Helping Athletes With Eating Disorders

So how can you apply this research on athletes and eating disorders to your own clients who engage in sports? Within the fitness environment, some clubs are hot breeding grounds for competitive thinness, whereas other facilities value diversity of size. How can you ensure that your club is the latter and not the former?

Often, fitness instructors and personal trainers proudly display their hard-earned bodies by wearing revealing attire. The trouble is, many clients may be using your body type as the ultimate model to which they aspire. So make it a policy to wear neat, professional, but not overly revealing clothes.

For many individuals with eating disorders, the fitness center is the place that motivates them to maintain their rigorous, demanding exercise regimens. Onsite staff—and other fitness professionals—should know how to recognize when a client has crossed the line from healthy exercise to exercise addiction.

Of course, it is not within fitness professionals’ scope of practice to diagnose or treat eating disorders. However, you do have many opportunities to interact with people suffering from these disorders and you can provide education or resources if clients approach you. (See the “Resources” sidebar, for useful websites and books by experts.) Individuals with eating disorders use fitness facilities to further their aim of weight loss. Their compulsion can be evidenced by the rigidity with which they train and the fact that they keep going beyond the fitness goals they have set. Since athletes tend to have the same drive to excel as compulsive exercisers have, it can be difficult to differentiate between the two. By not fully recognizing what’s behind a client’s drive to constantly work out and strive to lose weight, you might actually expedite the pace of an eating disorder without even realizing it. But by remaining vigilant, you can become part of the solution, even if you cannot directly intervene to assist a client whom you suspect of having a disorder.

New Guidelines for Fitness Professionals

Very few studies have assessed how fitness professionals view eating disorders, be it their own disordered relationship with food and exercise or that of their clients.

However, all that may change with a study that is scheduled for publication in the March–April 2008 issue of Eating Disorders: The Journal of Treatment and Prevention (Manley, O’Brien & Samuels, in press). The goal of this new study was to determine what fitness professionals do when they suspect a client has an eating disorder and to assess the ethical and liability issues of such a situation.

The researchers surveyed fitness instructors and pediatricians as to how they would handle a described case involving a client with suspected anorexia. The researchers found that 32% of fitness instructors suspected that the client had anorexia, compared with 88% of the pediatricians, a statistically significant difference. Of the fitness instructors, 60% recognized that there were ethical and liability issues to consider, and 37% considered these issues to be serious in nature. Tellingly, all of the fitness instructors suggested that guidelines in this area would be most helpful. One specific issue the instructors wanted clarification on was whether it was okay to refuse to allow a client with a suspected eating disorder to attend their class.

The implications of this latest piece of research are profound for fitness professionals. Although it can be argued that diagnosing and treating eating disorders is not the role of trainers or instructors, it is certainly within their capacity to recognize warning signs of what are potentially severe medical conditions. One option that is highly effective is to create a “sport management” team in which a group of professionals (consisting of the fitness pro, a physician, a psychologist and a registered dietitian) work in collaboration to help clients. In this scenario, fitness professionals could receive some specialized training from other team members on working with clients with eating disorders and exercise addiction.

Drawing Conclusions

A fitness professional can and should learn to work effectively with eating disordered or exercise-dependent athletes. But in order to succeed in this venture, it is imperative that you first honestly examine your own issues in regard to exercise, diet and the role that both play in your life. Understanding what motivates people with eating disorders and exercise addiction can help you facilitate a healthy, balanced lifestyle for these special clients.

SIDEBAR: When Is Exercise Excessive?

In her book Body Wars: Making Peace With Women’s Bodies (Gurze Books 2000), author Margo Maine provides the following test to determine whether you are overexercising. If you recognize your own behavior in these criteria, you know you are overdoing things:

You judge a day as good or bad based on how much you exercise.

You base your self-worth on how much you exercise.

You never take a break from exercise, nomatter how you feel or how inconvenient it is.

You exercise even though you are injured.

You arrange work and social obligations around workouts.

You cancel family and social obligations to exercise.

You become angry, anxious or agitated when something interferes with your workout.

You sometimes wish you could stop, but you are unable to.

You know others are worried about how much you exercise, but you do not listen to them.

You always have to do more (laps, miles and weights) and rarely feel satisfied with what you have accomplished.

You count how many calories you burn whileexercising.

You exercise to compensate for overeating.

SIDEBAR: Symptoms of Common Eating Disorders

Anorexia Nervosa Symptoms

preoccupation with food and exercise

irrational fear of being overweight or becoming fat

distorted body image

significant body dissatisfaction

low self-esteem

depression, fear, anger, anxiety and irritability

difficulty expressing emotion in a direct manner

perfectionism, obsessiveness and a high need for achievement

all-or-nothing thinking

high need for approval (fear of disapproval)

conflict avoidance

Bulimia Symptoms

preoccupation with food and exercise

relentless pursuit of thinness

unusual eating habits and behaviors (binging and purging)

low self-esteem

impulsivity or low sense of self-control

affective instability (depression, anger, anxiety)

difficulty expressing emotion in a direct manner

low tolerance for frustration

all-or-nothing thinking

significant body dissatisfaction

people pleasing and high need for approval

Binge Eating Disorder Symptoms

overeating, accompanied by a feeling of extreme guilt and loss of control

rapidly eating a large amount of food in a short period of time

eating when not hungry

eating in secret

feeling disgusted, depressed and/or guilty after eating

Disordered Eating Symptoms

having extensive knowledge about food and its energy/fat content

weighing oneself frequently

eating secretly

overexercising to compensate for eating

being preoccupied with weight, body image and other food issues

constantly dieting and gaining weight back

constantly thinking about the next meal

Source: Yager & Powers 2007.

SIDEBAR: Dos and Don’ts for Fitness Professionals

Dos:

Do educate yourself on the medical risks associated with common eating disorders.

Do know that denial will be very pervasive in clients with eating disorders and that lies and deceit will be used to cover up the severity of the compulsion.

Do be open and receptive, not judgmental.

Do realize that bulimia is just as serious as anorexia.

Do observe your own body image issues and clothing attire and recognize how both can affect a client’s self-image.

Do stay in close contact with the doctor and other professionals who are treating your client who has an eating disorder.

Don'ts:

Don’t glamorize thinness.

Don’t diagnose—leave that to the medical professionals.

Don’t oversimplify an eating disorder.

Don’t give advice about how to stop the behaviors.

Don’t become the person’s therapist, savior or victim.

Don’t promise to “keep” the client’s secret; you will need to reach out to a team of professionals to get the client help.

Don’t be inactive during an emergency. Get medical assistance right away.

SIDEBAR: Resources

Websites

www.edreferral.com (website for eating disorder professionals)

www.gurzebooks.com (eating disorder resource catalog for books)

www.healthywithin.com (eating disorder treatment center in San Diego)

www.nationaleatingdisorders.org (information for professionals, as well as prevention ideas)

Divya Kakaiya, PhD, CEDS, is the clinical director and owner of Health Within Inc., an outpatient program for individuals with eating disorders and body image concerns, based in San Diego. She is a nationally recognized clinician, author and presenter in the field of eating disorders and has developed specialized programs for athletes with eating disorders. She can be reached at www.healthywithin.com.